eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Toxicology

Toxicity, Digitalis: Follow-up

Author: Kenneth T Kwon, MD, Director of Pediatric Emergency Medicine, Associate Clinical Professor, Department of Emergency Medicine, University of California at Irvine Medical Center
Contributor Information and Disclosures

Updated: Nov 6, 2008

Follow-up

Further Inpatient Care

  • Consider the hospital admission of any patient with a history of a large ingested dose, especially if coexisting risk factors increase his or her susceptibility to digoxin toxicity.
  • Admit a patient to intensive care unit if he or she has signs or symptoms of toxicity.
  • Any patient receiving Fab fragments requires observation in an intensive care setting for at least 24 hours.
  • Patients who have had an unintentional exposure but no signs or symptoms of toxicity after 12 hours can be discharged from the hospital.

Deterrence/Prevention

  • Individualizing the dosing of cardiac glycosides appears to be the key to their optimal use. The desired plasma concentration endpoint is 2 ng/mL in patients younger than 2 years and 1.5 ng/mL in patients older than 2 years.
  • Medical, nursing, and pharmacy staff should carefully monitor the prescription, dispensing, and administration of digitalis. These personnel can help to prevent errors in dosing by paying careful attention to decimal points.

Complications

  • Arrhythmias can cause inadequate tissue perfusion with resultant CNS and renal complications such as the following:
    • Hypoxic seizures
    • Encephalopathies
    • Loss of vasoregulation
    • Acute tubular necrosis
  • Hyperkalemia is the major electrolytic complication in acute massive digitoxin poisoning. In pediatric patients, hyperkalemia can be a complication of acute toxicity.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose digitalis toxicity

Special Concerns

  • Fetal myocardium has an increased resistance to the toxic effects of digitalis.
 


More on Toxicity, Digitalis

Overview: Toxicity, Digitalis
Differential Diagnoses & Workup: Toxicity, Digitalis
Treatment & Medication: Toxicity, Digitalis
Follow-up: Toxicity, Digitalis
References
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References

  1. Litovitz TL, Normann SA, Veltri JC. 1985 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med. Sep 1986;4(5):427-58. [Medline].

  2. Smith TW, Butler VP Jr, Haber E, et al. Treatment of life-threatening digitalis intoxication with digoxin- specific Fab antibody fragments: experience in 26 cases. N Engl J Med. Nov 25 1982;307(22):1357-62. [Medline].

  3. Woolf AD, Wenger T, Smith TW, Lovejoy FH Jr. The use of digoxin-specific Fab fragments for severe digitalis intoxication in children. N Engl J Med. Jun 25 1992;326(26):1739-44. [Medline].

  4. Zucker AR, Lacina SJ, DasGupta DS, et al. Fab fragments of digoxin-specific antibodies used to reverse ventricular fibrillation induced by digoxin ingestion in a child. Pediatrics. Sep 1982;70(3):468-71. [Medline].

  5. Antman EM, Wenger TL, Butler VP Jr, et al. Treatment of 150 cases of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments. Final report of a multicenter study. Circulation. Jun 1990;81(6):1744-52. [Medline].

  6. Beller GA, Smith TW, Abelmann WH, et al. Digitalis intoxication. A prospective clinical study with serum level correlations. N Engl J Med. May 6 1971;284(18):989-97. [Medline].

  7. Bismuth C, Gaultier M, Conso F, Efthymiou ML. Hyperkalemia in acute digitalis poisoning: prognostic significance and therapeutic implications. Clin Toxicol. 1973;6(2):153-62. [Medline].

  8. Ekins BR, Watanabe AS. Acute digoxin poisonings: review of therapy. Am J Hosp Pharm. Mar 1978;35(3):268-77. [Medline].

  9. Fazio A. Fab fragments in the treatment of digoxin overdose: pediatric considerations. South Med J. Dec 1987;80(12):1553-6. [Medline].

  10. Hastreiter AR, van der Horst RL, Chow-Tung E. Digitalis toxicity in infants and children. Pediatr Cardiol. Apr-Jun 1984;5(2):131-48. [Medline].

  11. Husby P, Farstad M, Brock-Utne JG, et al. Immediate control of life-threatening digoxin intoxication in a child by use of digoxin-specific antibody fragments (Fab). Paediatr Anaesth. Jul 2003;13(6):541-9. [Medline].

  12. Kaufman J, Leikin J, Kendzierski D, Polin K. Use of digoxin Fab immune fragments in a seven-day-old infant. Pediatr Emerg Care. Jun 1990;6(2):118-21. [Medline].

  13. Lewander WJ, Gaudreault P, Einhorn A, et al. Acute pediatric digoxin ingestion. A ten-year experience. Am J Dis Child. Aug 1986;140(8):770-3. [Medline].

  14. Ordog GJ, Benaron S, Bhasin V, et al. Serum digoxin levels and mortality in 5,100 patients. Ann Emerg Med. Jan 1987;16(1):32-9. [Medline].

  15. Rutledge J. Digitalis toxicity in infants and plasma digoxin levels. Pediatr Cardiol. 1985;6(1):51-2. [Medline].

  16. Shumaik GM, Wu AW, Ping AC. Oleander poisoning: treatment with digoxin-specific Fab antibody fragments. Ann Emerg Med. Jul 1988;17(7):732-5. [Medline].

  17. Aarnoudse AL, Dieleman JP, Stricker BH. Age- and gender-specific incidence of hospitalisation for digoxin intoxication. Drug Saf. 2007;30(5):431-6. [Medline].

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Further Reading

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Keywords

digitalis toxicity, digitalis poisoning, acute digitalis poisoning, digoxin, digoxin poisoning, digoxin intoxication, cardiac glycosides, cardiac glycoside toxicity, Digitalis purpurea, headache, seizures, diarrhea, chromatopsia, xanthopsia, amblyopia, scotomata, decreased visual acuity, hyperkalemia, hypokalemia, hypomagnesemia, hypercalcemia, quinidine, procainamide, amiodarone, calcium channel blockers, beta-blockers, diuretics, hypothyroidism

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Contributor Information and Disclosures

Author

Kenneth T Kwon, MD, Director of Pediatric Emergency Medicine, Associate Clinical Professor, Department of Emergency Medicine, University of California at Irvine Medical Center
Kenneth T Kwon, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

William T Zempsky, MD, Associate Director, Assistant Professor, Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
William T Zempsky, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
Jeffrey R Tucker, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, and Massachusetts Medical Society
Disclosure: Merck Salary Employment

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD, Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin
Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society
Disclosure: Nothing to disclose.

 
 
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